Chronic glomerulonephritis

Pool of end-stage glomerular disease fed by a number of

streams of specific types of glomerulonephritis
Primary glomerular diseases
Rapidly progressive GN
Focal segmental glomerulosclerosis
Membranoproliferative GN
Membranous GN
IgA nephropathy
Poststreptocoocal GN
 Chronic glomerulonephritis
Insidious onset
Loss of appetite, nausea, weakness, anemia
Edema nephritic/nephrotic
Hypertension, proteinuria, azotemia
history of renal disease
Progressive
 Chronic glomerulonephritis
Renal mass

Blood flow, filtration, transcapillary P

Cell injury

Leakage of proteins, inflammatory infiltrate,

mesangial cell proliferation
 Chronic glomerulonephritis
Tubulo-interstitial fibrosis
Glomerular sclerosis
Peritubular capillary blood supply compromise
Ischemia of tubule segments downstream from
sclerotic glomeruli
Inflammatory infiltrate
Activation of tubular cells
 Chronic glomerulonephritis
Morphology
Contracted kidneys , with
granular cortical surface
Thinned cortex
Hyaline obliteration
of glomeruli
Arterial and arteriolar
sclerosis as a result of
hypertension
Chronic glomerulonephritis
Chronic glomerulonephritis
 Chronic renal failure
1. Diminished renal reserve
GFR is about 50% of normal
Serum BUN and creatinine values are normal

2. Renal insufficiency
GFR is 20 to 50% of normal
Azotemia appears, usually associated with anemia and
hypertension

3. Renal failure
GFR is less than 20% to 25% of normal
Edema, metabolic acidosis, hypocalcemia
Overt uremia, with neurologic, GI, and cardiovascular
complications

4. End stage renal disease

GFR is less than 5% of normal

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DISEASES AFFECTING TUBULES
AND INTERSTITIUM
 DISEASES AFFECTING TUBULES AND
INTERSTITIUM
Tubular injury
--- Acute tubular necrosis (ATN)
--- Acute renal failure (ARF)
Ischemia
Toxins
Tubulointerstitial nephritis
Inflammatory
 ACUTE TUBULAR NECROSIS
clinicopathologic entity characterized morphologically
by destruction of tubular epithelial cells and clinically by
acute diminution or loss of renal function
most common cause of acute renal failure
can be caused by a variety of conditions
Ischemia
Direct toxic injury to the tubules
Acute tubulointerstitial nephritis
DIC
Urinary obstruction
 ACUTE TUBULAR NECROSIS
Reversible renal lesion
Could be
ischemic ATN
nephrotoxic ATN
critical events in both ischemic and nephrotoxic ATN
are believed to be
1) tubular injury and
2) persistent and severe disturbances in blood flow
 Clinical Course
Highly variable
Prognosis of ATN depends on the clinical
setting surrounding its development
Up to 50% of patients with ATN might not have
oliguria and might in fact have increased urine
volumes
so-called nonoliguric ATN occurs particularly often
with nephrotoxins, and it generally tends to follow
a more benign clinical course
 Tubulointerstitial Nephritis
A group of inflammatory diseases of the
kidneys that primarily involve the interstitium
and tubules
Secondary involvement
Glomerulonephritis
Vascular diseases
 Tubulointerstitial Nephritis
Etiology
Infections
Acute/chronic pyelonephritis
Toxins
Metabolic diseases & neoplasms
Physical factors
Immunologic disorders

Acute / Chronic
 Acute pyelonephritis
Suppurative inflammation of the kidney and the
renal pelvis caused by bacterial infection
Tubules, interstitium, renal pelvis
UTIs
Lower
Upper
 Acute pyelonephritis
Pathogenesis
Etiologic agents
Enteric gram-negative rods
Escherichia coli
Proteus, Klebsiella, Enterobacter, and Pseudomonas
Viruses, fungi
Routes of infection
Hematogenous
Ascending infection
Acute pyelonephritis
 Acute pyelonephritis
Predisposing conditions
Urinary tract obstruction
Instrumentation
Vesicoureteral reflux
Pregnancy
Diabetes mellitus
Immunodeficiency
Clinical features
Onset is sudden with pain at the
costovertebral angle , fever, chills & rigor
Sometimes indication of bladder irritation
such as dysuria, frequency, urgency can occur
Urine contains leukocyte (pyuria) & pus cast
Definitive diagnosis is made by urine culture
 Acute pyelonephritis
Clinical features
Sudden onset
Pain
Fever, malaise
Sx of lower UTI
Urine
Pyuria
WBC casts
finding of leukocyte casts, typically filled with neutrophils (pus
casts), indicates renal involvement, because casts are formed
only in tubules
 Acute pyelonephritis
Morphology
Patchy interstitial suppurative inflammation
Intratubular aggregates of neutrophils
Tubular necrosis
 Three complications of acute pyelonephritis are
encountered in special circumstances
Papillary necrosis- diabetics and in those with
urinary tract obstruction
Pyonephrosis
Perinephric abscess
 Chronic pyelonephritis

- It is an important cause of end stage renal

disease
Chronic pyelonephritis can be divided into
Reflux associated
Obstructive
 Morphology
Grossly, kidneys are irregularly scarred with dilated, blunted &
deformed calyces
interstitial fibrosis and an inflammatory infiltrate of
lymphocytes, plasma cells, and occasionally neutrophils
Tubules show atrophy in some areas & hypertrophy or dilation
in others
Dilated tubules may be filled with colloid casts thyroidization
NB: kidneys usually are irregularly scarred; if bilateral, the
involvement is asymmetric VS Chronic GN
 Clinical features
It has insidious onset & present with manifestation of
acute pyelonephritis with backpain , fever, frequent
pyuria & bacteruria
Gradual onset of renal insufficiency & HTN
Polyuria & nocturia occur due to loss of tubular function
Some patients may develop focal segmental
glomerulosclerosis